A Newly Licensed ASC in an Existing Building-Processes, Challenges, Insights & Lessons Learned

AIA AUSTINCOMMITTEE FOR

HEALTHASC PRESENTATION

September 18, 2009

AgendaI. Introduction

II. Preplanning, Accreditation, Licensure and Operation- Nan Finch, RN, MSN, CNS – Diverse

Heath Consulting (President)

III. PreDesign/Design Considerations- Craig Puccetti, AIA – Lawrence Group

(Associate Principal)

-Tamara Toon – Lawrence Group (Associate)

IV. Construction Intricacies- Seth Bonnecarrere, LEED AP-Flynn

Construction, Inc (Project Manager)

Preplanning, Accreditation, Licensure and Operation

Game Plan

**Note: Importance that all players specifically have Licensed Surgery Center Experience

Education-Physician-Realistic Timeline

Financing - ProformaMission StatementSpecialties - PartnersNumber of RoomsTiming Expectations - 1 year PLANRFP

Team Selection** All major players on board early on

Owners Rep/Construction/Program Manager

Contracting - Insurance ConsultantClinical ConsultantEquipment Planner/ConsultantGeneral Contractor (as early as

Schematic-Never TOO early)Credentialing ConsultantMarketing RepresentativeHealthCare Architect and Consultants

-MEP -Structural-Civil-Interior Design

-Interior Finishes,Furnishings, Artwork & Signage

Concept Plan (Test Fit)

Application to DSHS, CMS & Accrediting Body

• Timing

• Info Requested

• Flexibility to change info providedFees

• Info required from Other Parties

Policies, Procedures & Administration

Establishing programs to meet licensing requirements

• Pharmacy – DEA• Lab - CLIA• Contracts – Laundry / Pathology /

Janitorial Services / Anesthesia / Pharmacy

• Logs• Internal Policies

-OSH-Clinical-Administration-Business Office-Environment of Care-Anesthesia

• Staffing-Hiring-Job Descriptions-Employee Handbooks-Types of Staff and Plans-EHR use and training

Final Inspection and Operation

State/Life Safety Inspection-Timing/Preparation /Fees-Process

Accreditation / Medicare Inspection-Timing/Preparation /Fees-Process

Open For Regular BusinessType of Patients for reimbursement Staff Competencies / TrainingReimbursement/TimingState Licensing/Accreditation / Medicare Certifications

Insurance ContractsOpen House / MarketingContinuous Follow-Up and Availability for Quality and

Success

DSHS Documentation-Maint. Logs

PreDesign and Design Considerations

Site & Building Evaluation (Physical Attributes)

Construction TypeCovered Canopy – Patient Drop off/Pick upCompliant ElevatorAccessible Parking and SiteAmbulance and Fire Dept. AccessCommon Areas/Patient Friendly AccessSeparated Use (vertical and horizontal)Building EnvelopeMultiStory Configurations-Patient Services on

more than 1 levelEgressingAccess ControlHazardous LocationsZoning and Use DesignationsShared Services (Space and Systems)

4 Story Existing POB

Site

IH-35

MAYS

HIGHLANDPROFESSIONAL

NN

Ground Floor

Roof Plan

Site & Building Evaluation CHECKLIST

1. Need to have a covered canopy or awning the will cover a car for patient drop off and pickup near the main entry point. Canopy or awning will be submitted for approval. Flatwork outside this entry could also be required to be accessible and provide accessible route from drop off/pickup to entry and discharge areas. Will a patient drop off and pick up area be possible?

2. Need location along back side of building adjacent to ASC where the diesel emergency generator can be placed. Will possibly need to access drives for refueling and add bollards or screen wall. A dumpster will also be required. A service area for deliveries of supplies and medical gas will also be preferred.

3. Will possibly want to add windows in facade at Operating Rooms and other Business areas. Additional doors for egressing may also be required on the ground level.

4. Will want to modify some storefronts for installation of new door systems including the main entry on the surgery center side. Main entry door will be upgraded with design approved by landlord.

5. At least 2 exterior doors from the ASC will need to be min 44" wide for wheelchairs.6. Consider getting a certain number of dedicated patient parking spaces near entry (where

applicable)7. Ensure that all site elements and entry points are accessible as per TAS requirements. 8. Ensure that adequate water pressure is available to support the the ASC when part of larger

development. Many times an ASC domestic water line is larger to handle the larger fixture demand.

Site & Building Evaluation CHECKLIST

9. Ensure that we are able to locate new hvac equipment on the roof, penetrate the roof, and upgrade structure to support units

10. When Multistory building with ASC on 2nd Level, Ensure that provisions are made to allow us to and accessible 5'x5' minimum cab size gurney elevator within lease space serving ASC if ASC is going to be located on 2nd floor. .

11 Ensure we have adequate electrical service and capacity to serve the ASC. A surgery center requires a larger service than a typical lease space

12. Verify construction Type. Is the building steel? If so, is it fireproofed or wrapped to be a rated assembly? Is there anything unique about the construction type like tilt wall exterior walls or post tensioned slab.

13. Verify if the building has a fireline/riser to the building if the building is fully sprinklered.14. Verify if possibility of modifying and or reinforcing floor /roof structure for new rooftop

equipment and clearances from existing exhaust fans and vents that are existing.15. Make sure we are not in a flood zone.16. Verify designed parking ratio.17. Verify that stairwells are strategically located so more than 1 means of egress is possible from

2nd floor occupancy.18. Verify Structural Clearances (floor to floor heights). 15 foot top of steel preferred.19. Are there any nuisance areas surrounding the site, high power lines, underground fuel

tanks....etc.

Site & Building Evaluation (Utility Infrastructure)

Available Building ServicesMedical GasDomestic Water including RO, DI or

Softened WaterWater Pressure to Building-Flow TestFire Sprinkler SystemTelephone/Fire Alarm SystemElectrical Service/Generator-Type 1

Essential Electrical SystemBuilding Air/Fresh Air/Pressurization

Building Construction Type and Structure

Vertical Clearances

Structural Considerations

Ceiling Heights/Plenum Clearances

Modifications to allow for Vertical Connectivity (Elevator)

Fire Rating

Building Section

Clearance Analysis

RCP

Plan Configuration & Code Issues

DSHS Licensing RulesJUNE 2009 REVISION

IBC vs. NFPA 101Occupancy Type

I-2 or B Occupancy???Mech/Support Room LocationsStaff, Patient and Support FlowMin. Facilities, SF Requirement,

tied to # of OR’sWindowless Anesthetizing

Location – Smoke Evacuation?

Fourth Floor

Rendering

Consultant SelectionMEP – Most ImportantPrior Experience with Licensed ASC –

Not just HospitalEquipment Overlay and MEP

Coordination - CRITICALSelection of Major Systems – Desired

OR TemperatureAir Change / Fresh Air

Requirements/Pressurization/Pre and Final Filtration of Air

Annunciators and Alarm SystemsPiped or Portable Medical GasDesign Build of MEP Systems (Fire

Protection)

Construction Intricacies

Pricing/Establishing Contract Price

Early Involvement – Team Approach

Pricing at Schematic, DD and CD (GMP Established)

Reconciliation of Actual Cost to Budget

Opportunities for Savings-Value Management Versus Value Elimination

Contracting – CM at RISK

Preferred Types of Contracts

Managing Changes

Responding to Owner Initiated Modifications / Options

Savings Split – Money Back to Owner!!

Establishing & Maintaining Schedule

Critical Path

Tracking

Identifying Long Lead Time Items

Submittal Timing

Managing Day to Day Construction Activities

Subcontractors and other On Site General Contractors

Inspections/City Requests

Process and Communication

Common Issues /Encountered Resolutions

Project Specific Challenges/Resolutions

Project Challenges

Electrical conduit, Plumbing, mechanical routing through occupied floors to surgery center and roof level

Precast floor and wall construction, and precautions that arise from this design

Installation of exterior elevator shaft in an occupied area, traffic and safety concerns

Above ceiling conditions and clearances at Operating rooms

Locating roof top unit with existing cell tower equipment and cabling

Project Close-Out/Post Occupancy/Successes

EXCELLENCE IN

CONSTRUCTION

DSHS Documentation

Final Test and Reports

As Built DocumentationO & M Manuals

Substantial Completion and Post Occupancy

Merit Award-Flynn Construction

DSHS Documentation

“Without reservation I would recommend Flynn Construction in the special and complicated area of Surgery Center planning and building”

-Dr. Mark Malone, Advanced Pain

“Lawrence Group worked closely with us from beginning to end resulting in a well coordinated project that exceeded Dr. Malone’s Goals and Expectations”

-David Wardell, Advanced Pain

“Nan was a great resource with getting us up an running quickly”-Caroline Domin, Advanced Pain

Testimonials

Before and After